Failure to Assess and Treat Pressure Ulcer on Admission
Penalty
Summary
Staff failed to assess and implement treatment for a pressure ulcer in a resident who was admitted with a stage 1 wound to the coccyx, as documented in the hospital discharge information. Upon admission, there was no evidence in the medical record that the wound was assessed or that a physician order for treatment was obtained. The first documented wound assessment and treatment order occurred seven days after admission, by which time the wound had progressed to a stage 3 pressure ulcer. The care plan initially addressed only the potential for pressure wounds and did not include interventions for an actual wound. Interviews with nursing staff and the DON confirmed that the resident's wound was not assessed at admission, and that treatment orders were not obtained until a week later. Staff indicated that if a resident refused assessment, they would continue to attempt assessment and notify the physician, but there was no documentation of these actions. The facility's policy required a skin assessment and Braden Scale on admission, as well as documentation of any skin abnormalities and physician notification, but these steps were not followed in this case.